New Patient Intake — Alberta Physical Therapy Clinic

Please complete the form completely. If you access treatment at this clinic for another problem in the future, a new form must be completed at that time. Direct any questions you may have to front-end staff at +1 (403)527-9477 or info@aptcinc.ca

"*" indicates required fields

Step 1 of 8

12%

Name*

First Last

Alberta Health Card Number*

Family Physician*

Birth Date*

MM slash DD slash YYYY

Address*

Street Address City Province Postal Code

Phone*

Email*

Description of problem for which you are currently seeking treatment:*

Is this the result of a Motor Vehicle Accident?*

Yes

The Alberta Physical Therapy Clinic is authorized to treat injuries as a result of a motor vehicle accident. If you have a valid MVA claim, we may be able to bill the insurance directly for your treatment costs. If your treatment costs are not covered under a claim, you are responsible for these charges.

Diagnostic Treatment Protocols Regulation Interpretative Guide is intended to streamline the process for both patients and primary health care practitioners. Under the DTPR, primary health care practitioners do not have to seek approval from the insurer to treat minor injuries and receive payment, although they are required to notify the insurer of the claim. Primary health care practitioners will then be able to bill the auto insurer directly for all treatment services outlined in the DTPR, unless covered by Alberta Health Care Insurance.

Date of accident*

MM slash DD slash YYYY

Vehicle Insurance Company*

Insurance Company's Phone Number*

Injury Adjuster*

Name of Policy Holder*

Claim Number*

Policy Number*

Insurance Company's Address

Street Address City Province Postal Code

Consent*

You have indicated that you have been in a motor vehicle accident. Important changes have been made to Alberta’s Insurance Act Regulations. As part of these changes, new protocols have been established for the diagnosis and treatment of minor injuries associated with motor vehicle collisions.

Your therapist will determine the extent of your injuries, and into which protocol you would be under.

The protocols apply specifically to three types of injuries: sprains, strains, and whiplash-associated disorders. Other injuries such as fractures, internal injury, etc. are excluded from these protocols. If you fall under the protocols, we will bill your insurance company directly for the determined number of treatments allowed by your insurance company.

Your insurance company should send you the forms that they require, the notice of loss, and proof of claim form (AB-1) should be completed by you within the first 10 days following your accident. We will complete and Fax the treatment plan (AB-2) form that you receive.

The charge is $40 for each appointment that is missed or canceled without 24 hours' notice. In the event that you cancel or are absent for 3 or more appointments, you will be discharged from active treatment.

I have read, understand, and will comply with the Above.

Did this injury occur at work?*

Yes

The Alberta Physical Therapy Clinic is an authorized WCB provider. If you have a valid WCB claim, we will bill them directly for your treatment costs. If your treatment costs are not covered under a claim, you are responsible for these charges.

You must have completed a “Workers Report of Injury or Occupation Disease” form in order to have your claim considered by WCB (this is different from the form your employer fills out). If you have not done this, they can be found on the Workers Compensation Board Alberta Website.

If you are uncertain as to the status of your claim, please contact your case manager or ask our staff, we may be able to help you to verify the status of your claim.

Name of Employer*

Employers Phone Number*

Employers Address*

Street Address City Province Postal Code

Date of Injury*

MM slash DD slash YYYY

WBC Claim Number*

Release of Information Consent*

The Workers’ Compensation Act gives WCB access to any or all information from your file with regards to this claim.
Rights of the injured Worker
• You have the right to understand what treatment you are getting and why.
• You have the right to refuse treatment. WCB has to be informed of any treatment that you refuse.
• You have the right to file a written grievance about anything in the clinic. Include your name, the staff involved and the detail of your grievance. Written grievances may be left at the front desk addressed to D. MacLeod.

By signing this, I consent for disclosure by WCB to Alberta Physical Therapy Clinics of any and all information relevant to my current condition.

In order to assist you in your return to work, WCB requests that we contact your employer to establish the critical job demands of your position and assess the availability of modified work duties. By signing this, I consent to Alberta Physical Therapy Clinics Contacting my employer to help facilitate my return to work.

I have read the release of information consents and agree to the terms outlined

Billing Agreement*

I understand that my treatment is being performed in trust and that WCB will be billed. If WCB denies my claim, I will be responsible for any outstanding debt incurred.

I understand that outstanding debt will be billed back to me or my insurance company.

The Charge is $40 for each appointment that is missed or canceled without 24 hours' notice. If you cancel or are absent for 3 or more appointments, you will be discharged from treatment. We must notify WCB of missed or canceled appointments.

I have read the billing agreement and agree to the terms outlined.

Are you claiming your treatment to a disability insurance?*

Yes

Insurance Company*

Claim Adjuster*

Claim Number*

Insurance Company's Phone Number*

Insurance Company's Address*

Street Address City Province Postal Code

Are you a Veteran?*

Yes

Veterans Affairs K Number

Canadian Armed Forces ID Number

Do you have extended health care benefits that covers physical therapy?*

Yes

Name of Insurance Company*

Name of Primary Insurance Holder*

Primary Insurance Holders Birth Date*

MM slash DD slash YYYY

Group Number*

ID Number*

Waiver For Treatment*

I, the undersigned, am aware that I am entering into Alberta Physical Therapy Clinics Inc.’s premises at my own risk. I am aware that tele-rehab is available to me and I can reduce risk by having treatment done this way.

Alberta Physical Therapy Clinics Inc and your physiotherapist are following the hand washing, cleaning, and disinfection protocols as set out by AHS and Physiotherapy Alberta as well as to provide you with the proper protective equipment, such as Masks, as well as gowns and gloves, are available if a patient wishes to wear them. Where possible, all aspects of social distancing will also be followed. Alberta Physical Therapy Clinics Inc. is, to the best of its ability, taking all steps necessary to adhere to the highest standard of preventative measures to decrease any risk to patients or staff.

As we are trying to work through the complexities of the times protocols may change. Please ask to see our procedure and protocol binder at any time.

By agreeing to this waiver, I release Alberta Physical Therapy Clinics Inc., including all of its officers and representatives of the clinic, from Liability for injury and illness. This includes COVID-19.

I have read, understand and will comply with the above statement.

Cancellation Policy*

The charge is $40.00 for each appointment that is missed or cancelled without 24 hours notice. In the event you cancel and/or are absent for 3 or more appointments, you will be discharged from active treatment.

I have read, understand and will comply with the above statement.